Organ Donor Hepatitis Test Error Transmits Virus to Recipient

The Centers for Disease Control and Prevention said Friday that two patients were tested positive for hepatitis C virus (HCV) infection approximately 6 months after receiving kidney transplants from a deceased donor who was incorrectly reported to be virus free.

Another patient received infected tissue from the same donor because of due to an incorrect negative test. The infection could have been avoided, however a CDC official said poor communication after the two kidney patients tested positive allowed the tissue transplant to continue.

Hepatitis C is an infectious disease primarily affecting the liver that can lead to cirrhosis, lung cancer, and other complications.

How the Infections Took Place

Before transplantation of the organs, the donor had tested negative for HCV antibody by the organ procurement organization.

Tissue was also taken from the organ donor and the tissue bank performed an HCV antibody test on the donor's serum specimen that was negative and nucleic acid testing (NAT) that was positive, but the test was misread as negative. Retesting of the donor specimen took place and confirmed that it was positive for HCV.

After the transplant center learned that the donor was infected they immediately reported the information but it was too late.

Need for Better Communication

Dr. Matthew J. Kuehnert, the CDC’s Director of the office of Blood Organ and Other Tissue Safety, said that transplantation of organs happens within 24 hours and more rapid communication between centers is needed.

“To prevent this from happening again we need an improvement in testing and better communication between organ and tissue groups,” Kuehnert told Medical Daily.

Kuehnert said a communications network was needed concerning outcomes of patients in organ and tissue transplants. He said it is something currently being worked on.

While two kidney recipients were infected with HCV, one liver transplant recipient was infected but had HCV prior to the transplantation, one tissue patient was infected, and 14 other tissue recipients who received the donors tissues were not infected, but one other recipient is currently in the process of being tested.